Kashiv P, Saxena K, Balwani MR, Pasari A, Kute VB. Alemtuzumab or basiliximab: Rethinking induction choice beyond acute rejection in kidney transplantation. World J Transplant 2026; 16(3): 118000 [DOI: 10.5500/wjt.118000]
Corresponding Author of This Article
Vivek B Kute, Professor, Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad 380016, Gujarat, India. drvivekkute@rediffmail.com
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Transplantation
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review-article
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World J Transplant. Sep 18, 2026; 16(3): 118000 Published online Sep 18, 2026. doi: 10.5500/wjt.118000
Alemtuzumab or basiliximab: Rethinking induction choice beyond acute rejection in kidney transplantation
Pranjal Kashiv, Khushboo Saxena, Manish Ramesh Balwani, Amit Pasari, Vivek B Kute
Pranjal Kashiv, Department of Nephrology, All India Institute of Medical Sciences, Nagpur, Nagpur 441108, Mahārāshtra, India
Khushboo Saxena, Department of Nephrology, Institute of Kidney Diseases and Research Center, Ahmedabad 380016, Gujarāt, India
Manish Ramesh Balwani, Department of Nephrology, Saraswati Kidney Care Center, Nagpur 440015, Maharashtra, India
Amit Pasari, Department of Nephrology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha 442001, Maharashtra, India
Vivek B Kute, Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad 380016, Gujarat, India
Author contributions: Kashiv P conceptualized the study, designed the methodology, collected data, performed analysis, and drafted the initial manuscript; Balwani MR and Pasari A provided critical supervision, conceptual guidance, and major revisions of the manuscript; Saxena K assisted in data collection, literature review, and preparation of figures and tables; Kute VB contributed to study design, interpretation of results, and final review of the manuscript for important intellectual content; all authors approved the final version and agree to be accountable for all aspects of the work.
AI contribution statement: In this paper, no AI tools were used to generate scientific content, interpret results or draw conclusions. Only AI tools (ChatGPT and Grammarly) were employed for language polishing, grammar correction and improving readability. We confirm that all original content, data analysis and scientific explanations were completely completed by the research team.
Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.
Corresponding author: Vivek B Kute, Professor, Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad 380016, Gujarat, India. drvivekkute@rediffmail.com
Received: December 22, 2025 Revised: January 12, 2026 Accepted: January 28, 2026 Published online: September 18, 2026 Processing time: 253 Days and 0.2 Hours
Abstract
In this review summarizes studies presenting a propensity-matched comparative analysis evaluating alemtuzumab vs basiliximab induction in kidney transplant recipients with aligned immunological risk profiles and extended follow-up. Alemtuzumab, a potent lymphocyte-depleting agent, has therefore been widely adopted on the premise that deeper early immune suppression confers durable graft protection. Whether this assumption holds true beyond the early post-transplant period remains uncertain. A recent study demonstrates comparable rates of acute rejection between induction strategies, effectively neutralising rejection as the differentiating endpoint in contemporary practice. In contrast, clinically meaningful divergence emerges in longer-term outcomes. Alemtuzumab induction is associated with inferior graft function, higher rates of cytomegalovirus and BK viremia, increased post-transplant malignancy, and greater death-censored graft loss. These findings highlight a central paradox in transplant immunology: Strategies that achieve potent early immune suppression may incur delayed biological costs related to immune reconstitution, impaired immune surveillance, and cumulative graft injury. Collectively, the data argue for a shift away from rejection-centred metrics toward a more proportional and individualised approach to induction selection, in which long-term graft preservation and complication risk are weighed as carefully as early rejection prevention.
Core Tip: Induction immunosuppression has traditionally been judged by its ability to prevent early acute rejection, yet long-term graft outcomes are increasingly shaped by factors beyond rejection alone. Contemporary evidence suggests that profound early immune depletion may confer delayed biological costs related to immune reconstitution, viral susceptibility, malignancy, and progressive graft dysfunction. The propensity-matched analysis discussed in this review highlight that alemtuzumab and basiliximab achieve comparable rejection control, while diverging meaningfully in long-term outcomes. These findings underscore the need to move beyond rejection-centred metrics and adopt a proportional, individualised approach to induction selection focused on durable graft preservation and patient safety.
